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4 Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning SUMMARY Parenting Practices â¢ Depression is significantly associated with more hostile, negative parenting, and with more disengaged (withdrawn) parenting, both with a moderate effect size. Findings are primarily related to moth- ers rather than to fathers. â¢ Depression in mothers is significantly associated with less positive parenting (warmth), with a small effect size. Findings are primarily related to mothers rather than to fathers. â¢ The poorer parenting qualities may not improve to levels com- parable to those of never-depressed parents, despite remission or recovery from episodes of depression. â¢ These patterns of parenting have been found in depressed mothers of infants and young children as well as in depressed mothers of school-age children and adolescents. â¢ Less is known about parenting in depressed fathers relative to mothers, but most of the findings from the smaller number of stud- ies are consistent with the findings about mothers. Child Functioning â¢ Depression in parents is associated with childrenâs poorer physical health and well-being. Infants and young children of mothers with 119
120 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN depression are more likely to use a variety of acute health care ser- vices. For older children and adolescents, there is limited evidence to suggest that depression plays a role in visits for stress-related health conditions and increased health care utilization. Adverse health outcomes of accidents, childhood asthma, child maltreat- ment, and adolescent tobacco and substance use occur more often when a parent is depressed. â¢ Maternal depression symptoms (and stress) levels are high among caregivers of children with chronic conditions. â¢ Depression in parents is associated with maladaptive patterns of health care utilization for children. Infants and young children of mothers with depression are more likely to use a variety of acute health care services. For older children and adolescents, there is limited evidence to suggest impact on health care utilization. â¢ Depression in parents has been consistently found to be associated with childrenâs early signs of (or vulnerabilities to) more âdifficultâ temperament; more insecure attachment; affective functioning (more negative affect, more dysregulated aggression and heightened emotionality, more dysphoric and less happy affect, particularly for girls; lower cognitive/intellectual/academic performance, cogni- tive vulnerabilities to depression (more self-blame, more negative attributional style, lower self-worth); poorer interpersonal func- tioning; and abnormalities in psychobiological systems, including poorer functioning stress response systems (neuroendocrine and autonomic) and cortical activity. â¢ Depression in parents has been consistently associated with a num- ber of behavior problems and psychopathology in children, includ- ing higher rates of depression, earlier age of onset, longer duration, greater functional impairment, higher likelihood of recurrence, higher rates of anxiety, and higher rates and levels of severity of internalizing and externalizing symptoms and disorders in children and adolescents. Mediators and Moderators â¢ Depression in parents is more likely to be associated with adverse outcomes in children with the presence of additional risk factors (e.g., poverty, exposure to violence, marital conflict, comorbid psy- chiatric disorders, absence of father when the mother has depres- sion, and clinical characteristics of the depression, such as severity and duration) than with depression that occurs in the context of more protective factors.
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 121 â¢ Parental functioning, prenatal exposure to stress and anxiety, ge- netic influences, and stressful environments appear to play a role in the development of adverse outcomes in children. ____________________ This chapter reviews what is known about the associations among de- pression in parents and parenting, child health, and child functioning, based on the large number of epidemiological and clinical studies that have docu- mented these associations. Throughout our work, the committee recognized that depression exists in a broader context of comorbidities, correlates, and contexts. In addition, there has been a growing body of research that sug- gests that parenting styles and processes are not necessarily universal and may differ and have differential impact on childrenâs behavior based on culture and ethnic group variations (Deater-Deckard et al., 1996). Thus, the literature was approached with a caution against interpreting outcomes as owing solely to the depression in the parent as a single risk factor. With this in mind, the committeeâs task was to review the literature that focused on (1) direct association between depression in parents and parenting, child health, and child functioning; (2) conditions that may make the association stronger or weaker (i.e., moderators); and (3) mechanisms or intermediate steps (i.e., mediators) through which depression in the parent becomes as- sociated with parenting or with outcomes in children. Although a review of the effects of parentsâ depression on the family (e.g., marital conflict) is not within the study scope, such effects are integrated into the literature sum- maries when findings bear on moderation (e.g., when maternal depression is more strongly associated with adverse child outcomes in the presence of high marital conflict rather than low marital conflict) or mediation (e.g., when maternal depression is associated with an increase in marital conflict, which is then associated with adverse child outcomes). PARENTING PRACTICES AND THE DEPRESSED PARENT Skills in parenting are key to facilitating healthy development in chil- dren. Qualities of parenting that have been found to be related to healthy development vary by age of the child. They range from the sensitive, re- sponsive caregiving especially needed by infants to the monitoring that is particularly needed by adolescents. Important aspects of effective parenting across development include providing age-appropriate levels of warmth and structure to help children feel safe and to help regulate their emotions (e.g., Cole, Martin, and Dennis, 2004). Children also are dependent on their par- ents to facilitate their education and to obtain their medical care.
122 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Parenting practices that do not meet infantsâ or childrenâs needs to sustain healthy development are one of the primary mechanisms through which parental depression exerts its effects on children (Goodman and Gotlib, 1999). As reviewed by Avenevoli and Merikangas (2006), there is evidence to support broad (e.g., stress), specific (e.g., parenting skills), and structural (e.g., divorce) family factors that explain or modify the associa- tion between depression in parents and childrenâs development of depres- sion or other problems. Although more research is needed to determine the effects of specific types of parent behaviors, it is evident that parenting behaviors associated with depression affect childrenâs adjustment. Indeed, a few studies have tested and found support for a mediation role of parenting in associations between depression and outcomes in children. For example, in a large, longitudinal, population-based study of Canadian youth ages 10 to 15, childrenâs reports of both positive parenting behaviors (i.e., nurturance and monitoring) and negative parenting behav- iors (i.e., rejection) mediated the relationship between parental depressive symptoms and childrenâs internalizing (e.g., anxiety, depressive symptoms) and/or externalizing (e.g., aggression, noncompliance) problems (Elgar et al., 2007). Also supporting mediation, Cummings et al. (2008) found that a community sample of 6-year-old childrenâs representations of their attachment to their parents and of interparental conflict partially mediated the relation between parental depressive symptoms and the childrenâs ex- ternalizing problems that emerged over the following 3 years. Lim, Wood, and Miller (2008), in a study of mothers with depressive symptoms and their children (n = 242, ages 7â17) with asthma symptoms recruited from pediatric emergency departments, also found evidence consistent with nega- tive parenting as a partial mediator of the relation between maternal depres- sive symptoms and childrenâs internalizing problems. However, despite the many strengths of this study, the reliance on a cross-sectional design limits conclusions that can be drawn about mediation. In addition to this support for parenting as a mediator, others have found that parenting serves as a moderator of associations between depression in parents and outcomes in children. Among research supportive of moderation is the finding that more positive outcomes in youth with depressed mothers were found among the subset of depressed mothers who used less psychological control, more warmth, and less overinvolvement (Brennan, Le Brocque, and Hammen, 2003). Researchers have accumulated strong evidence directly linking depres- sion in parents with problematic parenting practices, primarily based on studies using direct observations of parents and children in families of depressed parents. In a meta-analysis of this research, Lovejoy et al. (2000) found significant and moderate effect sizes for the association between both maternal depressive symptoms and disorder and hostile negative parenting
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 123 (e.g., negative affect, coercive, hostile behavior; mean d = 0.40), disengaged (withdrawn) parenting (e.g., neutral affect, ignoring; mean d = 0.29), and a small but significant adverse association with positive parenting behaviors (engaging a child in a pleasant or affectionate way; mean d = 0.16). These studies reflect the significance of disrupted parenting when a parent suf- fers from depression and underscore the usefulness of direct observations of parent-child interactions in these families. The authors conclude that depressed mothers who are preoccupied are more likely to become angry when children misbehave or make normal demands on them. Lovejoy et al. (2000) argue that the âfindings support the need for intervention with depressed mothers, as their parenting behaviors are a component of the risk associated with living with a depressed motherâ (p. 588). Despite the strength of findings linking depression and parenting, the analyses were limited by the literatureâs focus on younger children. Only 17 percent of the studies in the meta-analysis (n = 8) included children ages 6 or older, and none of the studies focused specifically on the high-risk period of early adolescence, a developmental period associated with increasing rates of depression and increasingly stressful parent-child interactions (Hankin and Abramson, 2001). A few more recent studies, however, have similarly supported links between depression and parenting even among parents of adolescents, as reviewed later in this chapter. Parenting practices are also of concern because they are associated with depression not only during periods of elevated symptom levels or during episodes that meet diagnostic criteria for depression but also when parents who have experienced depression may be relatively symptom free. Negative parenting has been found to persist even after controlling for the presence of major depressive disorder, suggesting that depressed parents continue to parent poorly following a depressive episode (Seifer et al., 2001). Depression and Parenting During the Prenatal Period, Infancy, Toddlerhood, and Early Childhood Although it is not common to consider that one engages in parenting behaviors during pregnancy, in fact there are multiple behaviors associated with depression during pregnancy that are relevant to childrenâs outcomes. These include obtaining prenatal care early and regularly, engaging in healthy patterns of eating (weight gain) and sleeping, and avoiding drugs, alcohol, and cigarettes. Both the symptoms of depression, such as anhe- donia (lack of pleasure in everyday experiences) and low energy, and the often correlated stressors may contribute to pregnant women neglecting their physical health and to engaging in behaviors that might provide im- mediate relief from distress, such as smoking, drinking, or unhealthy eating. Also, pregnant women with depression-related low energy or lethargy may
124 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN seek less prenatal care or begin their care later in pregnancy than women without depression. Furthermore, depression symptoms, such as appetite or sleep disturbances, suggest that pregnant women with depression may get inadequate nutrition or sleep. All of these behaviors raise concern for fetal development. Among the empirical findings, depression during preg- nancy has been associated with more smoking, greater consequences from alcohol use, and poorer overall health (Marcus et al., 2003; Zuckerman et al., 1989). Also, greater total sleep time during the third trimester predicted elevated depression symptoms postpartum (Wolfson et al., 2003). Among adolescent parents with depression, the poorer health behaviors are espe- cially strong (Amaro and Zuckerman, 1991). A much larger literature has shown depression, especially in moth- ers, to be associated with qualities of parenting of infants and toddlers. Researchers who observed mothers in face-to-face interaction with their babies or toddlers found higher levels of depressive symptoms to be associ- ated with less maternal responsiveness or sensitivity, less verbal and visual interaction, and more intrusiveness (Campbell et al., 2004; Civic and Holt, 2000; Easterbrooks, Biesecker, and Lyons-Ruth, 2000; Ewell Foster, Gar- ber, and Durlak, 2007; Horwitz et al., 2007; Marchand and Hock, 1998; Murray et al., 1996a; NICHD Early Child Care Research Network, 1999; Oztop and Uslu, 2007). Goodman and Brumley (1990), in a home obser- vation study, found that depressed mothers were emotionally unavailable and withdrawn to the extent that they were less sensitive to their childrenâs behavior, relative to women with no depression. Palaez et al. (2008) found that mothers with elevated depressive symptoms were more likely to be classified as authoritarian or disengaged in their interactions with their toddlers in comparison to mothers with low levels of depressive symptoms. Although mostly limited to small samples and to studies of elevated depres- sion symptom levels rather than diagnoses, and with typically moderate ef- fect sizes, these findings provide consistent support for associations between depression in mothers and patterns of interaction with their infants or young children that are intrusive/harsh or withdrawn/disengaged or both. Each of these parenting styles presents significant risks to the development of infants and toddlers. Parenting of infants is particularly of concern given its essential role in childrenâs development of secure attachment (Sroufe et al., 2005). Sen- sitive, responsive caregiving has been found to be the strongest predictor of secure attachment, which raises concerns given findings on depressed parents being less responsive and sensitive. Even beyond infancy, a sense of âfelt securityâ has been found to be essential for healthy development and for preventing the development of psychopathology (Davies, Winter, and Cicchetti, 2006). Other aspects of parenting of young children that have been found
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 125 to be associated with depression are behaviors related to the health and well-being of children. For example, a community study of 400 children entering kindergarten in New York (Kavanaugh et al., 2006) reported that mothers with high levels of depressive symptoms were less likely to take their children for dental care (odds ratio = 2.6), read to their children less (odds ratio = 2.6), and were less consistent in their use of discipline (odds ratio = 2.3) than mothers with normal results from depression screening. This theme is also reflected in reports of elevated depressive symptoms in mothers being associated with less use of well-child care by age 12 months, more infant hospitalization, less back positioning for sleeping, and fewer up-to-date vaccinations (Chung et al., 2004; Mandl et al., 1999; Minkovitz et al., 2005). Radke-Yarrow et al. (1993) conducted a landmark study of unipo- lar and bipolar depressed mothers and controls and their children, all of whom were under age 8 at study entry. To briefly summarize the findings, they found depression in a mother to be associated with (1) problems in functioning in essential and routine roles, (2) failure to help the child achieve self-regulation, (3) anger and irritability or enmeshing dependency or both, (4) less consistency of mother-child relationship over time, and (5) escalating negative qualities of interaction over time. Radke-Yarrow et al. concluded that psychopathology in a child was especially promoted when the motherâs behavior interfered with the childâs fundamental tasks, such as self-regulation; long-term dependable security, autonomy, and dependency needs; and positive attitudes about self. Middle Childhood and Adolescence Although direct observations of parent-child interactions in samples of depressed parents with older children and adolescents have been less common than with infants and younger children, a few studies have tested and found support for the hypothesis that depression is associated with parenting of adolescents and that the affected parent-child interactions may represent a crucial pathway for parental depression to the development of psychological problems in the adolescents (e.g., Gordon et al., 1989; Simons et al., 1993). Jaser and colleagues (2008) examined the associations between mater- nal mood and parenting behaviors through direct observations of mothers with and without a history of depression interacting with their adolescent children during a positive and a negative task. Mothers with a history of depression were significantly more likely to exhibit sad affect and disen- gaged and antisocial parenting behaviors than mothers with no history of depression across the two interactions, but these differences were largely ac- counted for by mothersâ current depressive symptoms. Mothersâ self-reports
126 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN of their current depressive symptoms were also related to higher levels of observed sadness and antisocial behaviors, as well as both childrenâs and mothersâ reports of maternal intrusive and withdrawn parent behaviors. Mothersâ prior history of depression and their current depressive symptoms were associated with higher levels of parent and self-reported internalizing problems in adolescents. Parenting associated with depression is thought to be experienced as stressful by children in middle childhood or adolescence, given that by middle childhood children have the cognitive capacity to perceive, interpret, and draw inferences about their parentsâ behavior. The stress of living with a depressed parent, relative to living with a parent with no depression, is characterized by more negative and unpredictable parental behaviors (e.g., irritability, inconsistent discipline), less supportive parental behaviors (e.g., less warmth, praise, nurturance, monitoring), and heightened marital con- flict (Cummings, Keller, and Davies, 2005). Similar to the situation with younger children, depression leads to disruptions in parenting of older children and adolescents as a result of parental withdrawal (e.g., social withdrawal, avoidance, unresponsiveness to childrenâs needs), parental in- trusiveness (e.g., irritability toward children, overinvolvement in their lives), or alternating behaviors between the two (e.g., Field et al., 1996; Forehand, McCombs, and Brody, 1987; Gelfand and Teti, 1990). Depressed mothers exhibit both intrusive and withdrawn behaviors, and the alteration or un- predictability itself may be perceived as stressful by their children (Gelfand and Teti, 1990; Jaser et al., 2005; Palaez et al., 2008). Exposure to these types of parental behaviors contributes to a chroni- cally stressful environment for children. As noted by Hammen, Shih, and Brennan (2004), âParenting quality, especially if perceived as being negative by the child, is itself stressfulâ (p. 512). A series of studies found that, ac- cording to parent and adolescent reports in a sample of adolescent children of depressed parents, adolescents were faced with the demands of moderate to high stress related to both parental withdrawal and parental intrusiveness in the past 6 months (Jaser et al., 2005, 2007; Langrock et al., 2002). Pa- rental withdrawal and intrusiveness were moderately positively correlated, indicating that children must cope with parents who exhibit both types of behaviors rather than with parents who are either withdrawn or intrusive. Stressful parent-child interactions characterized by parental withdrawal and parental intrusiveness were significantly correlated with higher levels of childrenâs symptoms of anxiety/depression and aggression. As with studies of younger children, studies of older children that were designed to test mediation have found that qualities of parenting at least partially mediate associations between depression in parents and the development of behavioral or emotional problems in their children. For example, Jaser et al. (2008) found that regression analyses indicated
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 127 that the relationship between current maternal depressive symptoms and adolescentsâ internalizing and externalizing problems were mediated by the observed sadness in mothersâ interactions with their children. Similarly, in one of the few studies that included mothers and fathers, Du Rocher Schudlich and Cummings (2007) found that disrupted parenting (e.g., parental rejection, lax control, and psychological control) by mothers and fathers partially mediated the relations between maternal and paternal dysphoric mood and childrenâs internalizing and externalizing problems. As described previously, a large-scale study recently found support for parental behaviors (nurturance, rejection, and monitoring) as mediators in the association between depressive symptoms in both mothers and fathers and 10- to 15-year-oldsâ emergence of emotional and behavioral problems (Elgar et al., 2007). These findings are strongly supportive of interventions to improve the quality of parenting in order to reduce the effects of parental depression on children. Maternal Depression Increases Risk for Punitive Parenting and Child Abuse As much as one needs to be concerned about depression in parents being associated with negative parenting qualities such as rejection, harsh- ness, and intrusiveness, it is of even greater concern that researchers find depression in parents to be associated with maltreatment of children. Much of the latter work has focused on the pathway from maternal history of child maltreatment to depression in the women and, ultimately, maltreat- ment of the children. Numerous studies demonstrate that a maternal his- tory of childhood maltreatment significantly increases a womanâs risk for major depression, substance abuse, and domestic violence (Edwards et al., 2003; Kendler et al., 2000; Lang et al., 2004; MacMillan et al., 2001; Spatz Widom, DuMont, and Czaja, 2007; Springer et al., 2007; Whitfield et al., 2003). These outcomes have, in turn, been clinically implicated as increasing the risk for subsequent maltreatment of the womanâs children, either by the woman herself or through her association with a perpetrat- ing partner (Collishaw et al., 2007; Hazen et al., 2006; Koverola et al., 2005; Thompson, Kingree, and Desai, 2004). Several studies have sought to empirically determine the relative contributions of maternal child abuse history and the longer term outcomes of maternal depression, substance abuse, and domestic violence to increased risk for maltreatment of children. Statistical models have focused on a variety of proxy outcome measures, including measures of parenting attitudes, punitive parenting, parental stress, or child abuse potential as quantified by the Child Abuse Potential Inventory (CAP), a 160-item measure of potential for physical abuse. Using path analysis with a sample of 265 predominately minority
128 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN women, Mapp (2006) found that the only route from experiencing mater- nal childhood sexual abuse to increased risk for committing child physical abuse, as quantified by the Parenting Stress Index, was through elevated maternal depression symptom levels as defined by a score of 16 or more on the Center for Epidemiologic Studies Depression Scale (CESD). In a sample of 107 sexually abused and 156 control first-time mothers recruited prenatally and followed up when their children were between 2 and 4 years of age, Schuetze and Eiden (2005) found that maternal depression (CESD â¥ 16) was significantly associated with harsh, punitive parenting when the mother was also experiencing domestic violence. They concluded that the relationship between maternal childhood sexual abuse and adverse parent- ing was indirect and was mediated by maternal depression and domestic violence. Comparing CAP scores in physically abused adolescent and adult mothers, de PaÃºl and Domenech (2000) found a significant interaction be- tween young maternal age, a history of severe physical abuse, and maternal depression that predicted significant risk for child maltreatment measured with the CAP. Using a structured clinical interview, Cohen, Hien, and Batchelder (2008) compared mothers diagnosed as substance abusing (n = 41), depressed (n = 40), and both depressed and substance abusing (n = 47) with control mothers (n = 48) and found that the combination of substance abuse and depression was significantly related to elevated CAP scores as well as to several other measures of aversive parenting. Banyard, Williams, and Siegel (2003), however, found that maternal depression was related only to poor parenting satisfaction but not to other measures of parenting dysfunction or to the actual incidence of child protection intervention in a sample of 174 low-income predominantly African American women, half of whom had documented histories of child sexual abuse. That finding may be explained by their use of a nonstandard measure of depression, a subscale of the Trauma Symptom Checklist, which may account for the lack of effect. Research thus indicates that maternal depression increases risk for child maltreatment when it occurs in some combination with other factors, such as a maternal history of maltreatment, maternal substance abuse, or domestic violence. Mediators and Moderators of Associations Between Depression and Parenting Given the strong and consistent evidence linking depression and parent- ing, it is important to ask what factors might mediate the relations between parental depressive symptoms and parenting behaviors. For example, as part of a larger study of parents of children with attention deficit hyperac-
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 129 tivity disorder (ADHD), Gerdes et al. (2007) found that the association of maternal depressive symptoms and lax parenting was mediated by maternal locus of control and maternal parenting stress, and the relation between maternal depressive symptoms and harsh, overreactive parenting was medi- ated by maternal parenting stress and maternal self-esteem. That is, beliefs about control over events in oneâs life, perceived parenting stress, and self- esteem explained at least part of the association between high symptom levels in mothers and their parenting approaches. Similarly, many factors are likely to moderate the relationship be- tween depressive symptoms and parenting behaviors, although few studies have provided direct tests. General systems and social ecological mod- els (Bronfenbrenner, 1980) suggest that a model to explain associations between depression and parenting must include potential influences be- yond the individuals involved. Mothers, including mothers experiencing depression, are embedded in systems that have the capacity to enhance or disrupt their responsiveness to their infants. Theory suggests that social support networks may operate by encouraging and modeling parenting skills (Bronfrenbrenner, 1979) or by serving as a resource for alternate child care, thereby minimizing the negative impact of stress on parenting (Cohen and McKay, 1984). Similarly, stress has been identified as a major determinant of qualities of parenting (Belsky and Jaffee, 2006). In studies of general populations samples of parents (not depressed parents), the effect of stress on parenting has been found to be contingent on social support (Crockenberg, 1981; Cutrona, 1984; Goldstein, Diener, and Mangelsdorf, 1996). Specifically, both stress and social support were found to signifi- cantly predict maternal attitudes and interactive behavior. Mothers with high stress were found to be less positive, while mothers with high social support were found to be more positive. Furthermore, social support has been found to moderate the effects of stress on maternal behavior (Crnic et al., 1983). For example, in a study of low-income African American mothers, although depression levels were not specified, mothers with larger support networks tended to be more respon- sive during interactions with their child (Burchinal, Follmer, and Bryant, 1996). The study also investigated the influence of structure on the effect of social support, finding that the source (father or grandmother) of social support through co-residence was associated with maternal responsiveness. Among the few studies that considered the role of stress and social support in associations between depression and parenting, the large-scale study by Radke-Yarrow (1998) found that, over time, the effects of mothersâ affec- tively symptomatic behaviors on the quality of the mother-child relationship were moderated by levels of family stress. Not only are qualities of parenting stressful for children of depressed parents, but also such children are exposed to a greater level of contextual
130 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN stressors. For example, Adrian and Hammen (1993) found that children of depressed mothers were exposed to stressful events in their families because of increased interpersonal conflict associated with the parentâs depression, and that family stress was also (along with depression in the mothers) an important predictor of both internalizing and externalizing problems in children. Stress clearly needs to be an integral part of a model of associations between depression in parents, parenting, and outcomes in children. As an example of the essential role of stress, Jones, Forehand, and Beach (2000) studied the role of maternal depressive symptoms and family relationship stress in a community sample. Mothersâ initial depressive symptoms gener- ated perceived stress in both marital and mother-adolescent relationships a year later. In turn, mother-reported family relationship stress exacerbated her depressive symptoms. Mother-reported stressful family interactions also contributed to higher levels of depressive symptoms in both adolescent girls and boys. Although no evidence of a family stress generation process for fathers was found, father-reported family relationship stress was associated with greater adolescent depressive symptoms. Beyond social support and stress, other moderators, which may in- crease or decrease the degree of association between depression and par- enting, are the level of depression symptom severity, being in or out of a depressive episode, and level of impairment. There is evidence that prob- lematic parenting behaviors persist, as depressed individuals continue to experience interpersonal impairment when not in a depressive episode (Hammen, 2003). However, more research is needed to determine how parenting qualities change in relation to exacerbation or improvement in depression symptoms. Depression in women who became mothers as teenagers is also a concern, with teenage parenting considered a moderator of associations between depression in parents and adverse outcomes in children. The subset of children of depressed mothers whose mothers gave birth as teenagers may be worse off than other children of depressed mothers. Being a teenage mother is an independent risk factor for depression and also for adverse outcomes for children, although not all such mothers become depressed and not all of their children develop problems. African American women who become mothers during adolescence are more likely to be depressed than their peers who delay motherhood (Deal and Holt, 1998; Horwitz et al., 1996). Teenagers who become pregnant have been found to engage in more maladaptive parenting behaviors than adult mothers (Garcia-Coll et al., 1986; Hann et al., 1994). They are less likely to be empathic and more likely to value physical punishment than adult mothers (Fox et al., 1987). In our review, we highlight studies that sampled teenage mothers for
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 131 their potential to help explain associations between depression in parents and child functioning. Summary The studies reveal well-replicated findings on the relation between parental depression and impaired parenting for children from infancy (and even fetal development) through adolescence. The findings from studies with extended theoretical models also show that the relation between de- pression and parenting is complex and needs to be considered in the con- text of a larger set of moderators and mediators, especially including other parental characteristics and the role of stress and social support. More research is needed to better understand this process. Next we turn to the literature that has examined associations between depression in parents and childrenâs physical and psychological health. Following that review, we return to parenting as we consider the role of parenting as a mediator of associations between depression in parents and aspects of functioning in children. DEPRESSION IN PARENTS AND CHILDRENâS FUNCTIONING Researchers have provided a wealth of data on the psychological and physical health of children whose parents have depression. Understandably, much attention has been focused on risk for the development of depression in the children. These findings are reviewed in this section, highlighting representative work. Researchers also expanded the scope of psychological outcomes studied in children of depressed parents to include other aspects of psychopathology, including other internalizing disorders as well as ex- ternalizing disorders. Other aspects of psychological functioning, some of which may themselves be developmental precursors, vulnerabilities, or early signs of disorder, are also included in this review. Similarly, physical health- related constructs include data on health or illness as well as childrenâs receipt of routine health care, safety of the home, and growth. Although a comprehensive review of that literature is beyond the scope of this project, we present representative findings and an overview of the conclusions that can be drawn. Limitations Stemming from Research Gaps For each aspect of childrenâs functioning that we examined in asso- ciation with depression in parents, we reviewed not only the evidence for associations but also any evidence for moderators and mediators of those associations.
132 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN As described in Chapter 2, moderators indicate for whom or under what conditions the associations are stronger or weaker. In the literature on children of depressed parents, the most commonly studied moderators include chronicity, severity, and timing of the parentâs depression, comor- bidities with the parentâs depression, and the role of the family and the larger social context, especially stress and social support. Each of these alone and in combination has the potential to exacerbate or protect against the risks to children associated with depression in parents. Empirical sup- port for moderators provides the information for targeting interventions to subgroups of children of depressed parents by revealing those who are at even greater risk for negative outcomes relative to others who also have a parent with depression. Another potential moderator that has generated interest is sex of the child and, when depression in both parents has been studied, the match between the sex of the parent with depression and the sex of the child. However, most studies did not report sex differences, and, as has already been studied, few studies included depression in fathers. Findings from these studies of sex differences are included in this discussion when available. Finally, although theory and related research suggests that a healthy and available second parent might moderate the effect of depres- sion in one parent on child functioning, few studies were found to support such moderation. Mediators are of particular interest because they reveal the mechanisms through which the depression in the parent becomes associated with the outcomes in the children, with implications for preventive interventions. As shown in Figure 4-1, the Goodman and Gotlib model (1999) identified the most empirically and theory-based mediators for how depression in parents has its effects on children. These are parenting, genetics, prenatal factors (if the mother had been depressed during pregnancy), and stress. Empirical support for mediators, if they precede the outcomes of concern, provides the information needed for designing interventions in that one would have support for targeting the identified mechanisms in an intervention experi- ment (Kraemer et al., 2001). For example, research showing that depres- sion in parents is associated with declining parenting skills and that the declining parenting skills at least partially explain associations between the depression and adverse outcomes in the children suggests that interventions designed to improve those parenting skills would benefit the children. With regard to genetics, there is a clear genetic risk for depression, as reviewed in Chapter 3. Thus, at least part of the associations found between depression in parents and childrenâs psychological functioning will be explained by genetics. Conclusions about heritability as a mediator, however, are depen- dent on studies with genetically informed designs such as twin or adoption studies or studies testing the mediating role of molecular genetics, that is, a specific genetic anomaly.
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 133 Risk Mechanisms Vulnerabilities Outcome Depressed Mother Heritability of Psychological Dysfunction Depression Skills Deficits or Maladaptive Childhood or Styles or Behavioral Tendencies Adolescent Depression Innate â¢ Cognitive Other Disorders â¢ Affective Dysfunctional â¢ Behavioral or interpersonal Neuroregulatory Moderators Mechanisms Father â¢ Availability â¢ Mental health Exposure to Motherâs Timing and Course of Negative and/or Motherâs Depression Maladaptive Cognitions, Characteristics of the Behaviors, and Child Affect â¢ Temperame nt â¢ Gender â¢ Intellectual and Exposure to social-cognitive Stressful skills Environment FIGURE 4-1â Integrative model for the transmission of risk to children of depressed mothers. Figure 4-1 contains Reprinted, with permission, from Goodman and Gotlib (1999). Copy- SOURCE: red rules and arrows right (1999) by the American Psychological Association. Knowledge of both moderators and mediators thus has clear and direct implications for prevention, as has been described in well-written papers that include a report on the prevention of mental disorders by the Institute of Medicine (1994). Despite these compelling reasons for identifying media- tors and moderators, our review revealed that most of the outcome studies did not use research designs that would allow identification of moderators or mediators. Thus we are limited in our ability to draw conclusions on these important questions. Another important consideration in evaluating this literature is a de- velopmental perspective, as outlined in Chapter 2. That is, it is essential to consider the normative developmental accomplishments expected of children at the ages at which the effects of parental depression are being studied as well as at the time of the childâs previous exposures, if any. This is especially important with the risk factor of parental depression given that depression is an episodic disorder. A further aspect of the developmental perspective is that children whose mothers are depressed may have moth- ers who were depressed during pregnancy and thus they were also exposed during fetal development. Maternal antenatal depression and its often ac- companying high levels of stress may be an early life stress that alters de-
134 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN velopmental processes associated with later hypothalamic-pituitary-adrenal (HPA) axis functioning, potentially resulting in dysregulated stress response systems that have been identified as vulnerabilities to depression (Heim, Plotsky, and Nemeroff, 2004; Kammerer, Taylor, and Glover, 2006). As with the limitations associated with knowledge of moderators and mediators, the literature is also limited in its ability to draw conclusions from a developmental perspective. Most of the outcomes studied are cross- sectional (both the parentâs depression and the childâs functioning were studied at the same time) rather than longitudinal (studying the parentâs depression and the childâs functioning at two or more times to see if changes in depression over time, such as increases in depressive symptom levels, ac- count for changes in child functioning, such as the emergence of psychologi- cal problems). Thus most knowledge is about specific outcomes associated with concurrent depression in mothers at specific child ages (e.g., 4-year-old children of mothers who are depressed at that time). We know less about the course of outcomes over time for children exposed at particular times, taking into account the childâs age when first exposed to depression in the parent (including potentially prenatally) and the chronicity and patterns of recurrence of the parentâs depression. The latter question is complicated by depression being recurrent and the possibility that correlates of depression that matter for children (especially stressors and parenting qualities) may or may not vary with the course of illness (being in episode or in recovery). It is also important to consider the transactional nature of child rearing, in that both parental depression and child functioning continue to influ- ence each other in an ongoing, cyclical manner throughout development (Elgar et al., 2004; Sameroff, 1975). In this review, we present a summary of what is known not only from the cross-sectional studies but also from the longitudinal studies and from studies that include pregnancy measures of depression. A further limitation of the literature is that the vast majority of studies of parental depression are on depression in mothers rather than fathers. Nonetheless, we reviewed the scant literature on depression in fathers. We also report on the Connell and Goodman (2002) meta-analysis in which we found that, although depression in both mothers and fathers has been shown to affect childrenâs psychological functioning, both internalizing and externalizing problems in children are more strongly associated with depression in mothers than with depression in fathers. For some children, the primary caregiver is the grandmother. Thus it is relevant to understand the prevalence of depression in grandmothers or grandfathers who care for their grandchildren, the effect of depression in grandparents on their grandchildren, moderators of those associations, and the role of parenting qualities and other mediators in those associations. The committee found very few studies addressing these points. Findings on
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 135 children raised by grandparents are also complicated by the often stressful circumstances that lead to that caregiving arrangement, such as father ab- sence, maternal drug use or incarceration, high stress and low levels of sup- port, exposure to trauma, and neglect (Gregory, Smith, and Palmieri, 2007). Given these added complications and the scarcity of the literature, we chose to not comprehensively review depression in grandparents who are primary caregivers. However, given the increasing frequency of such family arrange- ments, this lack of studies represents a critical research gap. One concern raised about this literature is that often the mother is the reporter on both her own depression and the child outcome (Kraemer et al., 2003). This has particularly raised questions given that one might suspect that depression may negatively bias the motherâs perceptions. We took note of Richtersâs helpful writing on concerns about depression influencing mothersâ reports on their children (Richters, 1992). Our review shows that researchers with well-designed studies to address this question continue to find small to moderate support for an association between higher levels of maternal depression and motherâs tendency to overreport child behavior problems, relative to a latent criterion variable (Boyle and Pickles, 1997; Fergusson, Lynskey, and Horwood, 1993). There remain important unre- solved questions about how to interpret this association. Thus in our review we noted when researchers included additional sources of data, at least for the child outcome, which was more common than not. Finally, another limitation of the research is that very few studies were designed to test transactional processes. In particular, little is known about the role of having a child with psychological problems on a parentâs de- pression, although there is more literature on the role of childrenâs physical health problems as a causal or exacerbating factor in parentsâ depression, on which we touch. Children with emotional, behavioral, or physical health problems may contribute to the causes of depression in parents or may ex- acerbate or help to maintain it once the parentâs depression has emerged. Physical Health and Health Care Utilization Consequences The health-related outcomes for children when a parent is depressed have been studied in several key areas. First, studies describe the health of the neonate when the mother experiences mental health issues. Second, studies examine how the children of mothers with depressive symptoms have different patterns of physical illness and health care utilization. Third, studies have investigated the role of maternal depression when the child has a chronic health condition. Fourth, investigations explore how the presence of parental depression is linked to a home environment that presents more health risks to the child. Finally, a few studies report on the occurrence of adolescent health risk behaviors when their depressed parents exhibit health
136 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN risk behaviors. In addition, the patterns of parenting with parental depres- sion often influence how parents supervise, monitor, and model healthy behaviors. Depression in the parent usually does not exist as a sole factor explain- ing health-related outcomes in these studies, as in studies of other outcomes. As has been described elsewhere in this report, depression is often accom- panied by the circumstances of social disadvantage, marital difficulties, and other coexisting mental health and substance use disorders, and it is acknowledged that any or all of these factors may play a role (independent, additive, mediating, or moderating) in determining health-related and other adverse outcomes for the children of depressed parents. Only a few studies have addressed all of these multiple factors. When the interaction of these factors has been addressed, they are noted. Most studies have investigated depressive symptoms in mothers, not the clinical diagnosis of depression. Except for adolescent reports, data on the impact of depression in fathers or depression in both parents are not available. Given the centrality of de- velopmental issues, we review this literature from that perspective. Newborns Antenatal depression, as well as stressful life events and anxiety, which often co-occur with depression, have been linked to complications of preg- nancy or delivery (e.g., preeclampsia) and adverse pregnancy outcomes (e.g., low birth weight), at least partially as a function of poor prenatal care and unhealthy habits (smoking, alcohol, drugs) (see the review by Bonari et al., 2004). Among low-income African American women, those with a high level of depressive symptoms were nearly twice as likely to have spontaneous preterm births (Orr, James, and Blackmore Prince, 2002). This was true even after controlling for other health risks related to premature birth. In a more recent, large, prospective cohort study that began early in pregnancy (Li, Liu, and Odouli, 2009), clinically significant levels of depressive symptoms were associated with almost twice the risk of preterm delivery relative to women with no depressive symptoms. Further, the risk for preterm delivery increased with higher levels of severity of depressive symptoms and the results were not associated with the use of antidepres- sants although they were associated with obesity and stress. Thus depressive symptoms in the mother, although associated with other health risks, played the central role in association with the negative outcomes for infants. The adverse effects of fetal and newborn elevated cortisol that occur with peri- natal maternal depression are discussed later in this chapter. In addition, mothers with depressive symptoms are also less likely to continue to breast- feed (Kendall-Tackett, 2005). Another concern about antenatal depression is fetal exposure to the motherâs antidepressant medication or substance
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 137 abuse during pregnancy, although we considered review of that literature outside the scope of this report. Infants and Young Children The social-environmental risk factors for child hospitalization in the first two years were examined in a Canadian cohort while controlling for biological risk factors. Elevated maternal depressive symptoms, single par- enthood, and income inadequacy each increased the risk of hospitalization 1.5 to 1.8 times, independent of the infantâs poor health and prematurity (Guttman, Dick, and To, 2004). In an ambulatory setting, even after con- trolling for socioeconomic factors, infants or young children of mothers with depressive symptoms were two times more likely to have more acute care visits and three times more likely to have an emergency room visit (Mandl et al., 1999). Among a prospective cohort of infants followed for the first year of life, infants of mothers with the diagnosis of depression were three times more likely to have acute care visits (Chee et al., 2008). The emergency department is another frequently used acute care venue. In a prospective study, after controlling for disease morbidity and other fac- tors, it was found that 6 months later inner-city mothers with high levels of depressive symptoms were 30 percent more likely to take their school-age children to an inner-city emergency department for asthma care than moth- ers with low levels of depressive symptoms (Bartlett et al., 2001). In another study, a diverse population of mothers who screened positive for depression were more than three times more likely to have had multiple emergency department visits and to have missed other outpatient visits, relative to mothers without depressive symptoms (Flynn et al., 2004). These increased rates of acute care visits and hospitalization were also found in two stud- ies of socially disadvantaged populations and one community cohort with children up to age 3 years (Casey et al., 2004; Chung et al., 2004; Minko- vitz et al., 2005). Maternal depressive symptoms have not been found to influence overall hospitalization rates for older children. However, in a prospective study of urban, economically disadvantaged, 4- to 9-year-olds with asthma, clinically significant maternal mental health symptoms were the strongest psychosocial predictor of hospitalization 9 months later (Weil et al., 1999). Further discussion of the influence of maternal depression on illness management for children with asthma in the inner-city setting is discussed later in this section. Studies that examined preventive health care utilization found it to be associated with depressive symptoms in mothers (Mandl et al., 1999; Minkowitz et al., 2005). Minkowitzâs study determined that higher levels of maternal depressive symptoms at 2 to 4 months postpartum predicted fewer well-child visits up to age 24 months in a prospective primary care
138 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN sample receiving augmented services to enhance child development. In a study of children starting school, maternal depressive symptom levels were not associated with childrenâs receipt of preventive health care services, but they were associated with childrenâs being less likely to have had preventive dental care (Kavanaugh et al., 2006). Women with clinically significant levels of depressive symptoms are more likely to report their childâs health at age 3 as fair or poor (Kahn et al., 2002). They are also more likely to seek clinical care for childhood somatic disorders, such as syncope (i.e., fainting; Morris et al., 2001), abdomi- nal pain (Levy et al., 2006; Zuckerman and Beardslee, 1987), headaches (Zuckerman and Beardslee, 1987), and injuries (Minkovitz et al., 2005). Increased accident rates have also been shown to occur when mothers are experiencing an episode of depression (Brown and Davidson, 1978). Among some subgroups of children with specific medical conditions, high levels of maternal depressive symptoms have been found to be more common. This includes conditions with associated psychosocial issues, such as failure to thrive (Stewart, 2007), ADHD (Johnston and Mash, 2001; Lesesne, Visser, and White, 2003), and chronic epilepsy (Shore et al., 2002), and conditions with high daily care demands, such as medical fragility (Meltzer and Mindell, 2006), ventilator technologyâdependent (Meltzer and Mindell, 2006), severe burn (El Hamaoui et al., 2006), and major developmental disabilities (Bailey et al., 2007; Manuel et al., 2003; Smith et al., 1993). Many of these studies assess depressive symptoms only on small, cross-sectional cohorts of children with specific diseases and do not determine the severity or chronicity of parental depression or illness course. Stress from caregiving, anxiety, lack of social supports, and disrupted care- giver sleep have all been shown to play a role in how a chronic condition relates to maternal depression (Boman, Lindahl, and BjÃ¶rk, 2003; Manuel et al., 2003; Meltzer and Mindell, 2006; Moore et al., 2006). These descrip- tive studies overall indicate that parental depression needs to be considered in these populations and that recognizing and treating the depression in parents may be an important adjunct to treatment of the child. As indicated above (Weil et al., 1999), the influence of maternal depres- sion on illness management has been studied more in depth for children with asthma in inner-city communities than for other illnesses or in other settings. In the prospective study of inner-city children with asthma, moth- ers with a high level of depressive symptoms, compared with mothers with lower levels of depressive symptoms, were less likely to adhere to medica- tion regimens prescribed for their children, more likely to have poorer un- derstanding of asthma illness management and poorer communication with the health provider, and were less confident in managing their childâs illness at home (Bartlett et al., 2004). In addition, the mothers with high levels
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 139 of depressive symptoms were 2 to 3 times more likely to report recently feeling helpless or frightened and upset by the childâs asthma. For families dealing with asthma, the role of maternal depression in disease control has been shown to be mediated by the childâs psychological problems as well (Lim, Wood, and Miller, 2008). Findings on depression being associated with parentsâ greater hostility and lower warmth/nurturance have also been replicated in low-income African American mothers of children with asthma (Celano et al., 2008), with implications for problems in parentsâ management of these childrenâs persistent health care needs. Maternal depression and related parenting issues play a role not only in the management but also in the development of asthma. Parenting dif- ficulties early in life, subsequent child psychosocial problems, and immu- noglobulin E levels at age 6 were significant predictors of asthma at ages 6â8 years in a longitudinal cohort at high risk for asthma (Klinnert et al., 2001). Maternal depressive symptoms measured at age 6 were strongly cor- related with key predictors, parenting, and child psychosocial problems. In a recent large birth cohort study, children with continued exposure over the first 7 years of life to mothers under treatment for depression and anxiety had higher incidence of asthma (odds ratio = 1.25) after controlling for asthma risk factors (Kozyrskyj et al., 2008). These effects were greater in high-income than low-income households. Only recently have studies been published that examine more closely the interface between maternal mental health, parenting, child behavior, and chronic disease management. These asthma studies illustrate how ma- ternal depression might play a role in adverse outcomes for childhood chronic physical health conditions when psychosocial factors influence the disease process and the diseases require careful parental attention to care management regimes and monitoring. Other health consequences may occur because of changes in the family environment associated with maternal depression. Mothers of young chil- dren with depression are more likely to be smokers (Whitaker, Orzol, and Kahn, 2006), thus exposing children to secondhand smoke that is associated with more respiratory problems (Neuspiel et al., 1989). In a longitudinal study of depressed parents, more respiratory illness was reported in children during middle childhood (Goodwin et al., 2007). Among preschoolers, the children watching the most television were predicted by two factors, ma- ternal depression and maternal overweight status (Burdette et al., 2003). Excessive television viewing in young children has implications for obesity and behavior. Other preventive health parenting practices that may limit optimal health and prevention of disease in children are discussed in the earlier section on parenting practices.
140 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Adolescents Although rarely studied compared with studies of infants or young children, adolescentsâ health care utilization also has been found to be as- sociated with depression in parents. In one study at 10-year follow-up, the children of a depressed parent were more likely to have been hospitalized. However, only the subgroup of children who had themselves developed depression had more medical problems reported by their late teens to mid- 20s (Kramer et al., 1998). Another report of these offspring after 20 years in middle age also showed an increase in the overall number of medical problems. Substance dependence was also more likely to develop during the adolescent years in this population (Weissman et al., 2006a). An issue that emerges with adolescence is health risk behaviors, such as the use of tobacco, alcohol, and drugs. It is well known that adolescent health risk-taking behaviors are closely related to parental alcohol and tobacco use patterns. It was particularly informative to note that, in a Ger- man longitudinal community study from early adolescence into early adult- hood, the odds of illicit drug use doubled if either parent had an affective disorder, even after controlling for parental use (Lieb et al., 2002). Rates did not increase further when both parents were affectedâthat is, even after accounting for parental use, an affective disorder in either the mother or father increased the likelihood of an adolescentâs beginning to use illicit drugs. Similarly, having a parent with depression was associated with a 40 percent increase in adolescentsâ alcohol and nicotine dependence, even after controlling for parental anxiety and substance use (Lieb et al., 2002). Overall, there is emerging evidence that depression, at least in moth- ers if not also in fathers, is related to the use of child health care services and adverse health outcomes in children, from infancy through adoles- cence. Moreover, the co-occurrence of maternal depression and a chronic health condition in the child places the child at additional risk of poor outcomes. Longitudinal studies that examine more closely the pathways by which depression influences health outcomes are needed to inform effective interventions. Child Psychological Problems and Well-Being Particular Aspects of Concern Researchers have studied a range of aspects of child psychological problems and well-being. Typically, the choice of what to study in the chil- dren is justified as being important both in terms of theories and research suggesting (a) why these aspects of functioning are likely to be affected by depression in parents and (b) why these aspects of functioning, if af-
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 141 fected, would be of concern regarding the potential for later development of psychopathology. Not surprisingly, much attention has focused on the likelihood of children of depressed parents becoming depressed themselves. Both theory about the mechanisms whereby maternal depression might contribute to depression in children (Goodman and Gotlib, 1999) and about the develop- mental pathways to the emergence of depression in children (Cicchetti and Toth, 1998) point to the importance of knowing more about associations between maternal depression and the emergence of depression in children and adolescents. Many of the studies of children of depressed parents have therefore examined associations between depression in parents and depression-related outcomes in their children, including depressive symp- tom levels and rates of depressive disorder. Some researchers have broad- ened the construct to internalizing disorders or problems in children, given that anxiety disorders are the most frequent co-occurring disorders in both clinical (Compas et al., 1997) and community samples (Lewinsohn et al., 1991) and that many researchers rely on symptom checklists that yield scores on internalizing problems as a broadband construct. Among other outcomes associated with depression in parents, research- ers have also been interested in externalizing disorders, since elevated rates of conduct problems have been noted since the earliest studies of children of depressed parents (e.g., Welner et al., 1977). From a theoretical per- spective, externalizing disorders in children with depressed parents are interesting because they may reflect problems with dysregulated aggression (Radke-Yarrow et al., 1992), a distinct pattern of inherited vulnerability perhaps related to behavior disorders (e.g., alcoholism, substance abuse, an- tisocial personality disorders) in first-degree relatives (Kovacs et al., 1997; Williamson et al., 1995). Alternatively, externalizing problems in children may reflect particular interactions among genes and cognitive, affective, interpersonal, and other biological systems that lead to the emergence of externalizing rather than (or co-occurring with) internalizing disorders. Although much of the literature has focused on psychopathology as outcomes for children with depressed mothers, a developmental psycho- pathology perspective requires an expanded definition of outcomes to also include competence or limits on ability to achieve typical development in the full range of affective/emotional, cognitive, and social/interpersonal functioning. A separate, important aspect of functioning that is essential to under- stand in children of depressed parents is temperament or behavioral ten- dencies. Difficulties in temperament associated with depression in parents could be observed, for example, through infantsâ behavioral tendencies to- ward less interest in and active exploration of their environment and novel stimuli, poorer organizational capabilities, and less soothability relative to
142 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN infants of nondepressed mothers. Mechanisms to explain such associations would primarily be heritability but could also include effects of prenatal exposures to maternal depression and correlated stress. Consistent with both explanations, fetal movement at 36 weeks gestation has been found to account for 21 to 43 percent of the variance in distress to limitations at 1 year and behavioral inhibition at 2 years (negative predictions), both indices of regulatory abilities (DiPietro et al., 2002). Temperament has also been of interest to parental depression researchers because it may be an early sign of vulnerability to the later development of depression (Hayden et al., 2006). Furthermore, temperament is of interest given transactional processes, which suggest that a depressed parent and an infant with a âdifficultâ temperament may face particular challenges in relation to each other relative to nondepressed parents or children who do not have these temperament qualities. For several reasons, researchers also have been interested in affective functioning, especially high negative affect and low positive affect in chil- dren of depressed parents (Cicchetti, Ackerman, and Izard, 1995; Garber, Braafladt, and Zeman, 1991). First is an understanding that how children manage their emotions may be early signs of some of the underlying person- ality traits associated with depression in adults (Klein et al., 2002). Second is research showing that high negative affect and low positive affect may be early signs of vulnerability to depression or even early signs of depression. Third, from the transactional perspective, is the understanding that infants and children with these affective tendencies will be especially challenging for parents with depression and may play a critical role in unfolding cycles of mutual negative influences. Children of depressed mothers may inherit a tendency to experience and express negative emotions (Plomin et al., 1993), may learn such a tendency through modeling, or may have heightened negative emotional- ity as a function of stress-related HPA axis dysregulation. Even in infancy, problems with negative emotions can be observed by infants showing more distress relative to others (Campbell and Cohn, 1997). Older children may experience more sadness relative to controls. Positive emotions might be equally important to examine as an out- come for children with depressed mothers, given that depression disorders are uniquely characterized by low positive affect or anhedonia (Clark and Watson, 1991). A dispositional tendency for low positive affect may pre- dispose children to the development of depression. Problems with positive emotions might be noted in infants observed to exhibit less positive affect or enjoyment (Cohn and Campbell, 1992) or in older children experienc- ing or expressing less positive affect relative to controls. Mechanisms that might help explain the occurrence of low positive affect in children with depressed mothers include heritability, the potential role of temperament
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 143 and a learned tendency to overcontrol positive affect (or a lower behavioral activation system) (Fowles, 1994), or a frontal lobe pattern of relatively greater left than right frontal cortical activity, which has been associated with lower positive affective responses (Davidson and Fox, 1989). Some aspects of emotional functioning are assessed with such measures as corti- sol as an index of stress reactivity, electroencephalogram (EEG) asymmetry as an index of a tendency to experience negative emotions, and infant neurobehavioral functioning as an index of newbornsâ abilities to control their behavior in response to the physical and social environment. Positive emotionality also has potential for being a partial mediator of associations between depression in parents and the later emergence of depression or other problems in their children. Findings suggestive of this idea include a study that showed that low levels of positive emotionality in 3-year-old children, measured with laboratory tasks and naturalistic observations, predicted higher levels of cognitive vulnerabilities to depression when the children were 7 years old, such as helplessness and depressogenic attribu- tional styles (Hayden et al., 2006). In addition to emotional functioning, childrenâs competency outcomes in social and cognitive realms are of interest in relation to depression in parents. Interpersonal functioning, ranging from responsiveness of infants to social functioning and competence in older children or adolescents, also is potentially tied to heritability (Goldsmith, Buss, and Lemery, 1997) and learning mechanisms. Deficits in interpersonal functioning are at the core of several theories of depression emerging in childhood (Bemporad, 1994; Cole, 1991; Hammen et al., 2003; Zahn-Waxler, 1993). Behavioral models of depression also suggest the importance of these social skills, traits, or tendencies, in that they could be associated with childrenâs lower likelihood of being reinforced if they lack certain skills or express other behaviors that result in a lack of rewarding relationships (Lewinsohn, 1974; Patterson and Stoolmiller, 1991). Similarly, cognitive functioning, especially the role of beliefs and atti- tudes, are central to the etiology of depression in children and adolescents (Garber and Martin, 2002; Hammen, 1992; Seligman et al., 1984), suggest- ing the importance of examining self-esteem, attributional style, and deficits in cognitive problem-solving skills. Another aspect of cognitive functioning, cognitive/intellectual functioning, is sometimes studied as an outcome in association with depression in parents, although it is sometimes conceptual- ized as a moderator in models of risk for children with depressed mothers (Goodman and Gotlib, 1999). Trouble concentrating and making decisions, as well as other symptoms, may emerge as early signs of depression in the children and have the strong potential to interfere with intellectual and academic functioning, while associated school failures may independently increase the risk of depression (Lewinsohn et al., 1994).
144 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN In the Goodman and Gotlib (1999) model (see Figure 4-1), these do- mains of child functioning are, for the most part, conceptualized as vul- nerability factors. These affective, interpersonal, behavioral, and cognitive variables are conceptualized as early markers of maladaptive processes that may be associated with the later development of psychopathology. We use the term âvulnerabilityâ to refer to individualsâ enduring or long-standing life circumstances or conditions that intensify maladaptive processes and thwart the achievement of successful adaptation (Cicchetti, Rogosch, and Toth, 1994; Masten et al., 1999). Risk factors, then, may include the ex- ternal factors, including depression in a parent as well as other family and broader socioenvironmental factors. Newborn Neurobehavioral Outcomes Researchers have reported varying degrees of consistency of support for associations between elevated levels of antenatal depression and poorer newborn neurobehavioral regulation. Studies shows consistent support for antenatal depression being significantly associated with newbornsâ greater inconsolability (Zuckerman et al., 1990), more crying/fussiness (Diego, Field, and Hernandez-Reif, 2005; Field et al., 2007; Zuckerman et al., 1990), more time in indeterminate sleep (Diego, Field, and Hernandez-Reif, 2005; Field et al., 2001, 2004), and more activity/movement (Field et al., 2004, 2007; Hernandez-Reif et al., 2006). Findings on infant alertness are less consistent, with one study finding a significant association with ante- natal depression (Hernandez-Reif et al., 2006), but two others finding no significant association (Field et al., 2007; Zuckerman et al., 1990). Higher levels of antenatal depression have also been found to be pro- spectively associated with less optimal scores on several subscales of the Neonatal Behavioral Assessment Scale (NBAS) (Brazelton, 1984). Field and colleagues have been at the forefront of studies revealing higher levels of antenatal depression being associated with less optimal scores on several subscales of the NBAS (Field et al., 2001, 2004; Hernandez-Reif et al., 2006; Jones et al., 1998; Lundy et al., 1999). Across publications, the most replicated finding was for antenatal depression to be associated with lower ability of a newborn to attend to visual and auditory stimuli and the quality of overall alertness. Effect sizes were typically in the range of 0.22 to 0.60. Most studies found that antenatal depression showed minimal to no sig- nificant association with newbornsâ ability to regulate their state in the face of external stimulation or in their having more abnormal reflexes. Other subscales were found to be significantly associated with antenatal depres- sion in some studies and not in others. The inconsistencies in the particular scales that are found to be associated with antenatal depression are likely to be explained by the variability in clinical characteristics of antenatal depres-
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 145 sion, which would be expected to be a moderator. The inconsistencies are not owing to how antenatal depression was measured, since all but one of the studies relied on symptom scales rather than on diagnoses. Another plausible explanation for the inconsistencies is comorbid al- cohol or substance use during pregnancy. Researchers have found high rates of antenatal depression co-occurring with cigarette smoking, alcohol consumption, and abuse of such substances as cocaine, often in combina- tion with each other (e.g., Amaro and Zuckerman, 1990, 1991; Amaro, Zuckerman, and Cabral, 1989; Zuckerman, Amaro, and Beardslee, 1987; Zuckerman et al., 1989). For example, depression is especially prevalent (35â56 percent) in samples of drug-dependent pregnant women (Burns et al., 1985; Fitzsimons et al., 2007; Regan et al., 1982). Temperament Several researchers have found that infants of depressed mothers, rela- tive to controls, have more difficult temperament. Whiffen and Gotlib (1989) found that infants of depressed mothers were perceived as more difficult to care for and more bothersome. A large study in Japan found direct effects of maternal depression on the infant temperament constructs of âfrustration toleranceâ and âfear of strangers and strange situationsâ (Sugawara et al., 1999). A meta-analysis found a significant, moderate cor- relation between postpartum depression and infant temperament, with a 95 percent confidence interval that ranged from 0.26 to 0.37 (Beck, 1996). Although relying on depressed mothers as reporters of their childrenâs temperament has raised concerns (Forman et al., 2003), researchers have found these significant associations even with lab-based measures of tem- perament (Goldsmith and Rothbart, 1994) and with self-report measures such as those developed by Rothbart (Garstein and Rothbart, 2003), which minimize maternal report bias by asking situation-specific questions and taking advantage of the extent and breadth of experience that mothers have with their infants. Among the potential moderators or correlated risk factors that have been studied, co-occurring anxiety in mothers has been found to play a role in associations between maternal depression and infant temperament, but the precise role is not clear. It may be that the anxiety, known to be highly correlated with depression, matters more. In one study, maternal trait anxiety predicted difficult infant temperament independent of antenatal and postnatal depression scores (Austin et al., 2005). Another study found that both anxiety and depression in mothers matter. One study, which measured temperament not only with maternal reports but also with observations, found that mild parental dysphoria and mild parental anxiety were associ-
146 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN ated with two dimensions of child temperament: attention and emotion regulatory difficulties (West and Newman, 2003). Some of the findings are informative of the developmental perspec- tive, especially of the role of transactional processes. In particular, some researchers have tested the hypothesis that infantsâ difficult temperament may increase the likelihood of postpartum depression. In one study, infantsâ difficult temperament was related to maternal depression in mothers of 3- month-olds, and this association was mediated by perceived efficacy in the parenting role (Cutrona and Troutman, 1986). In another study, maternal depression and infant negative emotionality interacted to predict maternal reactivity/sensitivity (Pauli-Pott et al., 2000). Positive infant emotionality was not a predictor. Good marital support was directly associated with maternal reactivity/sensitivity, but not as a moderator. In a direct test of the role of transactional processes, one group of re- searchers found that maternal depression and difficult infant temperament, but also fear/shyness, may interact to predict negative outcomes for chil- dren as adolescents, but the results vary by temperament factor, the child outcome, and gender. For example, in a longitudinal study that spanned ages 5 through 17, exposure to maternal depression in early childhood predicted increases in boysâ externalizing behavior problems over time only among boys whose temperament factor of impulsivity was low (Leve, Kim, and Pears, 2005). Others have found that children with more difficult temperament are more vulnerable to the effects of inadequate parenting, such as that found to be associated with depression in mothers (Goldsmith, Buss, and Lemery, 1997). Mothers of more difficult infants also perceive their parenting to be less efficacious, which in turn is linked to depression in mothers (Cutrona and Troutman, 1986; Porter and Hsu, 2003). Future research not only needs to continue to address the role of child tempera- ment but also needs to include measures of temperament, parenting, and parentsâ depressive symptoms that are not limited to maternal self-report for all of these variables. A few researchers have addressed potential mediators of associations between depression in parents and childrenâs temperament, focusing on influences on fetal development. Antidepressant medication treatment dur- ing pregnancy, at least in one study, did not predict temperament (Nulman et al., 2002). However, other prenatal or fetal processes may matter. One study found that elevated maternal cortisol at 30â32 weeks of gestation, but not earlier in pregnancy, was significantly associated with greater maternal report of infant negative reactivity, with additive predictions from prenatal maternal anxiety and depression, even after controlling for postnatal ma- ternal psychological state (Davis et al., 2007). In another study, at 2 and 6 months postpartum, mothers who had been depressed in pregnancy and/or postpartum, compared with nondepressed mothers, reported more difficult
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 147 infants at both times, even after controlling for histories of maternal abuse or prenatal anxiety (McGrath, Records, and Rice, 2008). Genetics is likely to be another mediator. Temperament itself is highly heritable (Hwang and Rothbart, 2003). Furthermore, genetics may explain associations between maternal depression and infant temperament (and the later development of depression or other disorders) (Gonda et al., 2006; Pezawas et al., 2005). That is, the same set of genes may predict both tem- perament qualities, such as negative affectivity and depression. From a methodological perspective, it is important to note that findings on depressionâs associations with child temperament are not the result of po- tential biases in depressed parentsâ perspectives. For example, not all stud- ies relied solely on depressed mothersâ perceptions of child temperament. In one study, not only depressed mothers but also their partners perceived their 2-month-oldsâ temperaments more negatively relative to nondepressed women and their partners (Edhborg et al., 2000). More broadly, current temperament questionnaire measures have been developed to minimize the contribution of reporter bias (Rothbart and Hwang, 2002). Finally, there is some evidence that difficult temperament is a partial mediator of associations between major depression disorders in parents and childrenâs development of depressive disorders. One longitudinal study, which followed children of depressed parents over a period of 20 years, showed the expected association between depression in one or both parents and having a difficult temperament (Bruder-Costello et al., 2007). Sec- ond, they found that difficult temperament in the children increased their likelihood of major depressive disorder. Third, they supported a partial mediational role of temperament in that childrenâs difficult temperament explained an additional 10 percent of the variance in associations between depression in parents and new episodes of major depression in the child. Attachment The association between depression in mothers and infantsâ less secure attachment relationships is well studied, with fairly consistent findings. There is sufficient literature that it has been subject to some meta-analyses. One meta-analysis reviewed effects of maternal mental illness (including both depression and psychosis) on quality of attachment in clinical samples (van Ijzendoorn et al., 1992). They found that maternal mental illness in- creased the likelihood of insecure attachment relative to norms and relative to samples of children with a range of problems. Another meta-analysis of 16 studies found that maternal depression was not associated with sig- nificantly higher rates of disorganized attachment in children relative to middle-class samples or to poverty samples (van IJzendoorn, Schuengel, and Bakersmans-Kranenburg, 1999). This was true even taking into account so-
148 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN cioeconomic status, type of depression assessment, and clinical versus com- munity samples. However, severely and chronically depressed parents were not targeted in this particular study population. Another meta-analysis, restricted to studies of clinically diagnosed depression in mothers, found that infants of depressed mothers showed significantly reduced likelihood of secure attachment and marginally raised the likelihood of avoidant and disorganized attachment (Martins and Gaffan, 2000). For example, clini- cally significant depression in mothers increased the likelihood of disorga- nized attachment from 17 to 28 percent on average. The reviewed studies predominantly sampled middle-income families with minimal risk factors other than the depression in the mothers. Thus, poverty and other risk fac- tors do not explain this finding. Affective Functioning Several studies have found support for associations between depres- sion in mothers and infantsâ or childrenâs greater negative affect relative to controls. Infants of depressed mothers show more negative affect (crying and fussing) and more self-directed regulatory behaviors (e.g., self-soothing or looking away) (Field, 1992; Tronick and Gianino, 1986). Toddlers show more dysregulated aggression and heightened emotionality (Zahn-Waxler et al., 1984), and adolescents (particularly girls) display more dysphoric and less happy affect (Hops, Sherman, and Biglan, 1990). In one study that examined depressive symptom levels in both mothers and fathers, mothersâ but not fathersâ depressive symptom levels were associated with preschool- age childrenâs low positive emotionality (Durbin et al., 2005). These studies predominantly, but not exclusively, sampled middle-class populations. Cognitive/Intellectual/Academic Performance Various indices of cognitive-intellectual or academic performance have reliably been found to be associated with depression in mothers. Children with depressed mothers, compared with children whose mothers are medi- cally ill or have other psychiatric disorders, have poorer academic perfor- mance and other behavioral problems in school (Anderson and Hammen, 1993). Children of depressed mothers or mothers high in depressive symp- tom levels have been found to score lower on measures of intelligence in several studies (Anderson and Hammen, 1993; Hammen and Brennan, 2001; Hay and Kumar, 1995; Hay et al., 2001; Jaenicke et al., 1987; Kaplan, Beardslee, and Keller, 1987; Murray et al., 1993; Sharp et al., 1995). This literature has been qualitatively reviewed from a developmental perspective, including the role of timing of the depression in the mothers (Sohr-Preston and Scaramella, 2006). For example, a large, federal, early
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 149 child care study found that chronicity of depressive symptoms over the first 3 years of life was related to maternal sensitivity, and maternal sensitivity moderated associations between maternal depressive symptom levels and 3- year-oldsâ school readiness and verbal comprehension (NICHD Early Child Care Research Network, 1999). Among the strongest evidence for moderators of the association be- tween maternal depression and academic functioning is exposure to violence (Silverstein et al., 2006). Essentially, in a large nationally representative sample of kindergarten-aged children, Silverstein et al. found that although depression in mothers was independently strongly associated with childrenâs lower reading, mathematics, and general knowledge, children who had also been exposed to violence scored even lower on those same skills. They also had more behavior problems compared with children who had been exposed to either maternal depression or violence alone. This pattern of findings was stronger for boys than for girls. School Dropout and Adolescent Sexual Behavior In a longitudinal study of offspring of depressed and nondepressed mothers followed annually from 6th through 12th grade, higher IQ was found to be protective of dropping out among offspring of never- or mod- erately depressed mothers but not for adolescents whose mothers had been chronically or severely depressed (Bohon, Garber, and Horomtz, 2007). Similarly, the presence of a male head of household was associated with lower rates of sexual behavior among adolescents of never- or moderately depressed mothers but not among adolescents whose motherâs depression was chronic or severe. Cognitive Vulnerabilities to Depression One of the strongest predictors of depression in adults and also in children is the presence of cognitive vulnerabilities. Thus, this has been of interest to researchers who study the children of depressed parents. Across multiple studies, depression in mothers and high levels of depressive symp- toms in mothers are associated with children, as young as age 5, showing early signs of cognitive vulnerability to depression, including being more likely than controls to blame themselves for negative outcomes, having a more negative attributional style, hopelessness, pessimism, being less likely to recall positive self-descriptive adjectives, and having lower self-worth (Anderson and Hammen, 1993; Garber and Robinson, 1997; Hammen and Brennan, 2001; Hay and Kumar, 1995; Jaenicke et al., 1987; Mur- ray et al., 2001). Adolescents with depressed mothers show early signs of cognitive vulnerability to depression, such as being more likely than other
150 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN adolescents to blame themselves for negative outcomes and less likely to recall positive self-descriptive adjectives (Hammen and Brennan, 2001; Jaenicke et al., 1987). Stress and Coping Of particular concern is a pattern of children of depressed mothers (current or past depression) being more reactive cognitively (e.g., being more likely to think pessimistically) when exposed to failure (Murray et al., 2001; Taylor and Ingram, 1999). They found, for example, that associations between adolescentsâ re- ports of parental stress and parentsâ reports of adolescentsâ anxiety/depres- sive symptoms were related to adolescentsâ self-reported use of secondary control engagement coping and adolescentsâ stress reactivity (Jaser et al., 2005, 2008; Langrock et al., 2002). Specifically, increased levels of parent- child stress due to parental withdrawal and parental intrusiveness were associated with higher levels of stress reactivity in children (e.g., heightened emotional and physiological arousal, intrusive thoughts, rumination). Con- versely, childrenâs use of coping strategies that involve acceptance of their parentsâ depression and efforts to reappraise it in more positive ways was related to lower levels of anxiety and depression in children of depressed parents. These findings suggest that teaching children of depressed parents to use more effective coping strategies may be an important target for pre- ventive interventions (Compas et al., 2002). Beardslee and colleagues have published several papers on this topic, going back several decades, which have informed understanding of the range of functioning in children and adolescents whose parents (mothers and/or fathers) have been depressed. They have found, essentially, that children of depressed mothers vary in their adaptive functioning, and those with more adaptive functioning function better. For example, more flex- ible approaches to coping and more situationally appropriate strategies are associated with better outcomes (a moderator relationship) (Beardslee, Schultz, and Selman, 1987; Carbonell, Reinherz, and Beardslee, 2005). Results from other studies by Beardslee and colleagues suggest that children may be protected by how they perceive and respond to depression in their parents (Beardslee and Podorefsky, 1988; Solantaus-Simula, Punamaki, and Beardslee, 2002a, 2002b). Specifically, youth who were resilient in the face of parental depression understood that their parents were ill and that they were not to blame for the illness. Findings from intervention studies in Beardsleeâs randomized trials are also tests of the role of these constructs in associations between depression in parents and childrenâs well-being (Beardslee et al., 2003, 2008). The concept of understanding on childrenâs part was operationalized to be un-
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 151 derstanding of the parentâs illness at both the fourth and sixth assessment points. Young people whose parents changed the most in response to the intervention had increased the most in understanding their parentsâ illness. Thus, it was possible to increase understanding through preventive inter- vention. Others note variability in adolescent childrenâs coping with mater- nal depression (Klimes-Dougan and Bolger, 1998). For example, children whose mothersâ depression is associated with more anger and irritability cope differently than others, boys differ from girls, and, even within fami- lies, siblings differ in how they cope with the motherâs depression. Interpersonal Functioning Beginning with studies of infants, researchers have identified problems in interpersonal functioning associated with depression in mothers. Field (1992) has shown that infants (1) match the negative affective expressions of their mothers when in face-to-face interaction with them, (2) look âde- pressed,â and (3) generalize these styles to the infantsâ interactions with others. She has also found that infants of depressed mothers whose inter- action style is characterized as withdrawn have poorer interactive qualities than those whose style is characterized as intrusive (Jones et al., 1997b). In multiple publications since the early 1980s, Tronick and Cohn have il- luminated the nature of infantsâ responses to face-to-face interaction with mothers who are depressed (Cohn and Tronick, 1983; Cohn et al., 1986). Among their more recent papers, they show that higher symptom levels in mothers and the infantsâ being male contributed to lower quality mother- infant interactions (Weinberg et al., 2006). Murray has studied infants, toddlers, and preschool-age children interactÂing with their depressed mothers. Although some of the studies controlled for other variables, such as conflict in the home, she found that the depression in mothers still accounted for the childrenâs quality of inter- action (Murray and Trevarthen, 1986; Murray et al., 1996b, 1999). Studies of young children interacting with their depressed mothers, best illustrated by the work of Radke-Yarrow and colleagues, revealed that children whose mothers have been depressed engage in excessive compli- ance, excessive anxiety, and disruptive behavior that, when the children were followed into adolescence, were found to persist over time (Radke- Yarrow, 1998). Among the few studies of peer interactions, sons but not daughters of depressed mothers were found to display more aggressive behavior during interactions with friends (Hipwell et al., 2005). Kindergarten-age children whose mothers were depressed were more often excluded by peers (Cummings, Keller, and Davies, 2005). The latter effect was mediated by the childrenâs exposure to interparental conflict. Adolescent children of
152 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN depressed mothers have poorer peer relationships and less adequate social skills than teens of nondepressed control mothers (Beardslee, Schultz, and Selman, 1987; Billings and Moos, 1985; Forehand and McCombs, 1988; Hammen and Brennan, 2003). Psychobiological Systems: Stress Responses and Cortical Activity Researchers have found significant associations between maternal de- pression and two psychobiological systems in children that have been found to play a role in emotion regulation and expression. The first is stress responses measured in either (a) autonomic activity (higher heart rate and lower vagal tone) or (b) stress hormonal levels (higher cortisol as an index of HPA axis activity). Field (1992) found that infants of depressed mothers have higher cortisol levels, especially following interaction with their de- pressed mothers (Field, 1992). Harsh parenting, which is sometimes associ- ated with maternal depression, has also been linked to higher cortisol levels in children (Hertsgaard et al., 1995). Both findings suggest an association between childrenâs HPA axis functioning and the depressed mothersâ failure to provide sensitive, responsive care. The second significant association with maternal depression is corti- cal activity in the prefrontal cortex and particularly the pattern of greater relative right frontal EEG asymmetries. This pattern is associated with the experience of withdrawal emotions in children and with depression in adults and adolescents (Davidson et al., 1990; Dawson, 1999; Dawson et al., 1992; Finman et al., 1989). Even 1-week-old infants of depressed mothers, as well as 1-month-old infants, showed greater relative right frontal EEG asymmetry compared with infants of nondepressed mothers, and these early EEGs are correlated with EEGs at 3 months and 3 years (Jones et al., 1997a), suggesting continuity of this effect. Dawson and col- leagues saw similar patterns in 18-month-olds (Dawson et al., 1997). These patterns show remarkable stability from as early as age 1 week to age 3 years, suggesting that the early measures are reliably detecting a pattern of individual differences (Dawson et al., 1997, 2003; Jones et al., 1997a). Further, although restricted to a small sample, Dawson found support for both contextual stressors (marital discord and levels of stress) and childrenâs frontal brain activation mediating the association between a history of maternal depression and childrenâs behavior problems when the children were 3 years old. Among possible moderators of associations between maternal depres- sion and childrenâs frontal brain activation are the extent of exposure to depression in mothers, especially prenatal exposure. For example, the number of prenatal months of exposure to maternal depression margin- ally predicted left frontal lobe activation from EEG (Ashman and Dawson,
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 153 2002; Dawson et al., 1997). However, depression during pregnancy was measured retrospectively when the mothers were 13â15 months postpar- tum, and depression was defined to include women who were in partial remission or subthreshold. If this finding is replicated, it suggests the need to examine such mechanisms as genetics and intrauterine factors for the association between maternal depression and frontal brain activity in pre- natally exposed infants. Other potential moderators yield mixed findings. For example, abnor- malities in neurobiological or neuroendocrine functioning in infants are sometimes specifically found to be associated with face-to-face interaction with their depressed mothers (Field, 1992) and with harsh parenting in particular (Hertsgaard et al., 1995), but others find them to reflect a more general trait (Dawson et al., 2001). Behavior Problems or Psychopathology The ultimate outcome of concern among children of depressed parents is the emergence of elevated levels of behavior problems or diagnosable psychopathology. Many studies show that rates of depression are higher in children with depressed mothers, whether the maternal depression is deter- mined by meeting diagnostic criteria or clinically significant levels of de- pressive symptom scale scores, relative to a variety of controls (Beardslee et al., 1988; Billings and Moos, 1985; Goodman et al., 1994; Lee and Gotlib, 1989; Malcarne et al., 2000; Orvaschel, Walsh-Allis, and Ye, 1988; Weiss- man et al., 1984; Welner et al., 1977). Studies with adolescents show the same. Adolescents with depressed parents have been found to have higher rates of depression (Beardslee et al., 1988; Beardslee, Schultz, and Selman, 1987; Hammen et al., 1987; Hirsch, Moos, and Reischl, 1985) as well as higher rates of other disorders (Orvaschel, Walsch-Allis, and Ye, 1988; Weissman et al., 1984) relative to controls. Overall, rates of depression in the school-age and adolescent children of depressed mothers have been reported to be between 20 and 41 percent, in contrast to general population rates of about 2 percent in children ages 12 and younger and 15 to 20 per- cent in adolescents (Lewinsohn et al., 2000). Higher rates among children of depressed parents are associated with greater severity or impairment of the parentâs depression and with the addition of other risk factors, such as those associated with poverty. Not only are rates of depression higher, but depression in children of depressed parents, relative to depression in same-age children of non- depressed parents, has an earlier age of onset and longer duration and is associated with greater functional impairment and a higher likelihood of recurrence (Hammen and Brennan, 2003; Hammen et al., 1990; Keller et al., 1986; Warner et al., 1992).
154 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Beginning in the preschool years, maternal depression is also associated with childrenâs and adolescentsâ higher levels of internalizing and external- izing behavior problems (attention deficit disorders and disruptive behavior disorders, including violence) and substance abuse (Brennan et al., 2002; Fergusson, Lynskey, and Horwood, 1993; Forehand et al., 1988), anxiety (social phobia, separation anxiety, and other anxiety disorders), and dys- regulated aggression and more externalizing problems, although some re- searchers have found the latter to be specific to daughters (Biederman et al., 2001; Luoma et al., 2001; Orvaschel, Walsch-Allis, and Ye, 1988; Weissman et al., 1984; Zahn-Waxler et al., 1990). The studies from Radke-Yarrowâs lab were also seminal in showing that even 5-year-olds of depressed mothers showed more dysregulated aggression and heightened emotionality and had more externalizing problems (Zahn-Waxler et al., 1984, 1990). Moderators include the sex of the child, clinical characteristics of the parentâs depression, and whether the depression is in the mother or the father. For example, maternal depression was associated with higher rates of internalizing problems (e.g., depression, anxiety) in 4-year-old boys and girls, but with externalizing problems (e.g., conduct disorder, attention defi- cit disorder) only in girls (Marchand and Hock, 1998). In middle childhood and adolescence, daughters of depressed mothers may be more likely than sons to show depression (Davies and Windle, 1997; Fergusson, Horwood, and Lynskey, 1995; Hops, 1996), although others have not found sex dif- ferences (Fowler, 2002). In terms of clinical characteristics, mothers who reported high levels of depressive symptoms reported higher levels of behavior problems in their 5-year-old children, with even stronger associations when those symptoms were severe, chronic, and recent (Brennan et al., 2000). Generally, as ex- pected, longer exposure is associated with worse outcomes for children (NICHD Early Child Care Research Network, 1999; Sohr-Preston and Scaramella, 2006; Trapolini, McMahon, and Ungerer, 2007). Surprisingly, conclusions regarding severity of depression are mixed; some have found that severity is a strong predictor of childrenâs emotional and behavior problems (Hammen and Brennan, 2003), and others have found only small associations (Radke-Yarrow and Klimes-Dougan, 2002). A few of the studies of psychopathology as an outcome for children or adolescents have tested the bidirectional or transactional roleâto what extent do problems in the children contribute to the depression in the par- ents? In two seminal studies on this topic, based on two distinct samples (Gross et al., 2008; Gross, Shaw, and Moilanen, 2008), most associations between maternal and paternal depression and childrenâs internalizing or conduct problems revealed that higher levels of both mothersâ and fathersâ depressive symptoms predicted later increases in childrenâs internalizing or conduct problems. At the same time, a few findings, specific to particular
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 155 ages, supported child effects on parental depression. For example, higher levels of aggressive behavior in 5-year-old boys predicted higher levels of maternal depression when the boys were 6 years old (Gross, Shaw, and Moilanen, 2008). These researchers also found that child noncompliance was more strongly associated with depression in mothers than in fathers (Gross et al., 2008). Across multiple studies, depression in mothers has been found to be more strongly associated with internalizing and externalizing problems in children relative to depression in fathers, as revealed in a meta-analysis (Connell and Goodman, 2002). Nonetheless, depression in fathers is of con- cern. For example, in a large cohort study, depression in fathers during the postnatal period predicted a greater likelihood of preschool-age boys and girls having emotional and behavioral problems and boys having conduct problems (Ramchandani et al., 2005). These findings were maintained even after accounting for postnatal depression in the mothers and later depres- sion in the fathers. A more recent study found that the problems in the chil- dren persist until age 7 (Ramchandani et al., 2008). Another study found different patterns of association with mothersâ relative to fathersâ depres- sion among young adults (age 24) who had experienced major depressive disorder by age 19 (Rohde et al., 2005). Major depression in fathers was associated with both sonsâ and daughtersâ lower psychosocial functioning, whereas for depression in mothers that association was specific to sons. Sons of depressed fathers also had higher levels of suicidal ideation and higher rates of attempts, whereas that association with depression in moth- ers was not significant. And recurrent depression in fathers but not mothers was associated with depression recurrence in daughters, but not sons. These studies suggest direct and specific associations between depression in fathers and the development of psychological problems in their children. In order to further examine the relationship of paternal depression to psychopathology in the child, the committee undertook an indepen- dent analysis of public use data from the National Comorbidity Survey- Replication (NCS-R) study. The NCS-R offered the opportunity to analyze a data set generalizable to the population in the United States in which the elements of a comprehensive theoretical framework consistent with the goals of our committee could be examined. We conducted our analysis separately among 759 male and 1,035 female respondents, ages 18â35 at the time of the NCS-R interview. The respondentsâ reported recall indicated that primary independent risk factors for self-reported major depressive disorder diagnosis (defined by Diagnostic and Statistical Manual of Men- tal Disorders, fourth edition) within the past 12 months were recalling â Tabulationsbased on the National Comorbidity Survey-Replication (see http://www.icpsr. umich.edu/CPES/).
156 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN (1) each of their parents having sad behavior for 2 or more weeks and (2) their parentsâ drug and alcohol problems during the respondentsâ childhood (defined as up to the age of 18). These analyses were conducted incorporat- ing the weighting and design effects from the NCS-R. Control variables in this framework included their parentsâ immigrant status and ethnicity and the respondentâs own age at interview and relationship status. Potential mediating variables in this framework included the respondentsâ recall of the level of closeness with each of their parents, their recall of each of their parentsâ social problems, their report of parental neglect during their child- hoods, and their report of the experience of trauma during childhood. We statistically tested the mediational effects of these factors and found that an alternate model in which these potential mediating variables were treated as covariates provided a better fit. Hence, we evaluated the independent and potential moderating effects of these variables in multiple logistic regres- sion analyses. In these logistic regression models, we retained independent variables that had p-values less than 0.10 and examined interactions (effect modification) among the variables that met this criterion. Interaction terms with p-values less than 0.05 were retained. In the models for both sons and daughters, the variables that consis- stently predicted major depression within the past 12 months were recalling having a father who had experienced sadness for 2 or more weeks during the respondentâs childhood and having had an experience of trauma before age 18. As shown in Table 4-1, in the multiple logistic regression model, we found that males who recalled their fathers having experienced sadness for 2 or more weeks during their childhoods had rates of major depression in the past 12 months that were modified by their fathersâ drug or alcohol problems during their childhoods (effect modification statistically signifi- cant, p = 0.01). Paradoxically, those whose fathers had experienced sadness and also had drug or alcohol problems during the respondentsâ childhood had lower rates of major depression in the past 12 months compared to those who fathers had neither risk factor, though this difference was not statistically significant. In contrast, those whose fathers experienced 2 or more weeks of sadness alone and those whose fathers had drug or alcohol problems alone had elevated rates of major depression compared to those with neither risk factor, with odds ratios of 3.65 and 1.73, respectively. In addition, the summary score of paternal closeness during childhood was highly significantly associated with major depression in the past 12 months (p = 0.01), with those who perceived less closeness to their fathers more likely to have major depression. Also, males who reported having expe- rienced trauma before the age of 18 were approximately 3.8 times more likely to have had major depression in the past year (p = 0.02). Among females, we again found that having a father who had sadness for 2 or more weeks during the respondentâs childhood was a strong (odds
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 157 TABLE 4-1â Multiple Logistic Regression Analysis of Major Depression in Past 12 Months Among Males Odds ratio (95% C.I.a) p-value Interaction of father sad for 2+ weeks during childhood with father had drug/alcohol problems during childhood (overall p = 0.01) Father sad, drug/alcohol problems vs. 0.37 (0.07, 1.95) 0.24 neither Father not sad, drug/alcohol problems vs. 1.73 (0.95, 3.15) 0.07 neither Father sad, no drug/alcohol problems vs. 3.65 (1.20, 11.14) 0.02 neither Mother sad for 2+ weeks during childhood 1.58 (0.79, 3.15) 0.20 Closeness of father: summary scoreb 1.39 (1.08, 1.80) 0.01 Race/ethnicity (overall p = 0.07) African-American vs. white 0.75 (0.32, 1.75) 0.51 Hispanic vs. white 0.85 (0.37, 1.94) 0.70 Other vs. white 3.64 (1.23, 10.71) 0.02 Any PTSD before age 18 3.23 (1.36, 7.69) 0.008 NOTES: PTSD = Posttraumatic stress disorder; N = 759, 65 with major depression, 694 without; model p-value = 0.003; generalized R2 = 0.10; C-statistic = 0.65. aConfidence interval. bFor a one standard deviation difference; higher values denote less closeness. SOURCE: Tabulations based on the National Comorbidity Survey-Replication (see http:// www.icpsr.umich.edu/CPES/). ratio 3.17) and statistically significant (p < 0.0001) predictor of major depression in the past 12 months (Table 4-2), as was experience of trauma before the age of 18 (odds ratio of 3.41, p < 0.0001). Additional statistically significant factors in the model for females predictive of major depression in the past year were lower levels of closeness to the mother during child- hood (p = 0.005), greater parental neglect during childhood (p = 0.047), a paradoxical effect of fewer social problems among the respondentsâ fathers (p = 0.047), increased depression with older age at the time of the interview (p = 0.03) and having never been married compared to having been married or co-habiting (p = 0.02). These findings underscore the importance of examining the effects of paternal risk factors as well as maternal risk factors for psychopathology in children and that comprehensive models are required to properly quantify the effects of these risk factors, many of which are intercorrelated and may show effect moderation. Further studies of this type are needed, especially those in which more detailed information on personal trauma and neglect
158 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 4-2â Multiple Logistic Regression Analysis of Major Depression in Past 12 Months Among Females Odds ratio (95% C.I.a) p-value Father sad for 2+ weeks during childhood 3.17 (1.80, 5.60) < 0.0001 Closeness of mother: summary scoreb 1.24 (1.07, 1.44) 0.005 â (higher values denote less closeness) Father social problems: summary scoreb 0.80 (0.65, 0.99) 0.047 â (higher values denote more problems) Parental neglect: summary scoreb 1.21 (1.01, 1.47) 0.047 â (higher scores denote more neglect) Ageb (years) 1.36 (1.03, 1.80) 0.03 Relationship status (overall p = 0.07) Separated, widowed, divorced vs. 1.37 (0.72, 2.59) 0.33 Married, cohabitating Never married vs. married, cohabitating 1.77 (1.09, 2.90) 0.02 Any PTSD before age 18 3.41 (1.98, 5.88) < 0.0001 NOTES: PTSD = Posttraumatic stress disorder; N = 1,035 (176 with major depression, 859 without); model p-value < 0.0001; generalized R2 = 0.12; C-statistic = 0.66. aConfidence interval. bFor a one standard deviation difference. SOURCE: Tabulations based on the National Comorbidity Survey-Replication (see http:// www.icpsr.umich.edu/CPES/). history can be included in public use data sets to be further analyzed, e.g., identifying the perpetrator of the trauma or neglect. Timing of Exposure The timing of exposure has received quite a bit of attention as a po- tential moderator, addressing the question: Is there a sensitive period for exposure to maternal depression? Some theories suggest that the first year of life, approximately, may represent a sensitive period given both infantsâ dependence on their caregivers and the centrality of responsive, sensitive caregiving for childrenâs development of secure attachment and other as- pects of emotion regulation (Essex et al., 2001). Two prospective studies conducted in Great Britain came to somewhat different conclusions regard- ing the role of postpartum depression alone in predicting adverse outcomes for children, regardless of subsequent episodes. Hay and colleagues studied youth from low-income homes. In contrast to cognitive development, for which postnatal depression has been found to be associated with childrenâs later cognitive functioning (at ages 11 and 16) regardless of subsequent exposures to maternal depression, postnatal depression plus at least one subsequent episode of depression in mothers predicted childrenâs behavioral
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 159 problems at ages 11 and 16 (Hay et al., 2001). In the other British study, which sampled from a more middle-income population, postnatal depres- sion exposure was associated with subsequent behavior problems (at age 5) and symptoms of hyperactivity and conduct disorder (at age 8) (Morrell and Murray, 2003). However, later follow-ups revealed that both postnatal depression and later episodes of depression in mothers predicted depression in the children at age 13, although anxiety was best predicted by postpar- tum exposure alone (Halligan et al., 2007). Others concluded that postpartum depression does not predict later functioning in children, but that it is later exposures that matter. For ex- ample, in a large study of predominantly low-income Australian mothers and their children, mothersâ recent depressive symptoms were associated with their 5-year-old childrenâs socioemotional problems, whereas their postpartum depression levels were not (Brennan et al., 2000). Other support for the conclusion that postpartum depression combined with later exposures is what matters for children comes from another British study, in which only postpartum depression that continued was associated with childrenâs behavior problems at age 15 months (Cornish et al., 2006) and age 4 years as reported by mothers, fathers, and teachers (Trapolini, McMahon, and Ungerer, 2007). Persistence of Problems Following Recovery or Remission Among studies that did not explicitly examine treatment for depres- sion in the parents, the small longitudinal literature reveals that, for the most part, childrenâs problems persist despite the mothersâ remission or recovery from depression. Typical of these studies are two that focused on children of preschool age through adolescence. Children of depressed par- ents continued to be at risk for psychological problems despite reductions in parentsâ depressive symptoms (Billings and Moos, 1985; Lee and Gotlib, 1991; Timko et al., 2002). Most of the longitudinal studies of infants and toddlers have drawn similar conclusions, that is, children of the recovered mothers showed fewer disturbances than the children of unrecovered moth- ers but greater disturbances than the children of control mothers who had never been depressed (Cox et al., 1987; Ghodsian, Zayicek, and Wolkind, 1984). Similarly, in a follow-up of low-income children ages 18 months to 4â6 years, Alpern and Lyons-Ruth (1993) showed that both the group of children whose mothers exceeded the clinical cutoff score on a depression rating scale at both times and the group whose mothers were previously but not currently depressed had more behavior problems than the children with never-depressed mothers. Maternal depression during the first postpartum year predicted lower cognitive ability at age 4 years regardless of the motherâs depression status
160 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN when the child was 4 years old (Cogill et al., 1986). Stein et al. (1991) found that 19-month-olds whose mothers had recovered from depression that had occurred during the first postnatal year showed lower quality in- teraction with their mothers and with a stranger than did children whose mothers had never been depressed. There are some exceptions to this finding, and these are intriguing. For example, Field (1992) reported that 75 percent of mothers who had been depressed early in the postpartum period continued to have symptoms at 6 months postpartum. The infants of the remaining 25 percent did not display a depressed style of interaction or have lower Bayley mental and motor scale scores at 1 year of age (Field, 2002). Another intriguing question that has been addressed by some of the longitudinal studies is: If parenting quality improves with remission of de- pression, do children benefit? A few studies help to answer that question. Campbell, Cohen, and Meyers (1995), for example, found that mothers who were depressed 2 months postpartum but whose depression remitted by 6 months were significantly more positive and more competent in feed- ing their infants relative to mothers whose depression was chronic through 6 months postpartum (Campbell, Cohn, and Meyers, 1995). Furthermore, the infants in the depression remission group were significantly more posi- tive in face-to-face interactions with their mothers than were those whose mothers remained depressed, although they did not differ significantly in terms of negative interaction or in the quality of engagement with their mothers in toy play. Some studies that included an active treatment component for the mothersâ depression also included mother-infant assessments, providing an opportunity to more directly test the hypothesis that parenting is one of the mechanisms in the transmission of risk from depressed mothers to their children. Treatment studies are reviewed in Chapter 6, but we focus here on the small subset of treatment studies that allow us to address this issue. A controlled trial of interpersonal psychotherapy in postpartum women with major depression, which was found to be effective in reducing levels of depression, also found significant improvement on self-reported measures of mothersâ relationships with their children associated with interpersonal psychotherapy, even though the women did not achieve the levels typical of women with no history of depression (OâHara et al., 2000). More recent studies continue to show that despite improvement in depression with in- terpersonal psychotherapy, mother-infant relationships were not improved (Forman et al., 2007). Similarly, Cooper and Murray (1997), with a community sample screened for depression, found that treated mothers (randomly assigned to either nondirective counseling, cognitive-behavioral therapy, or dynamic psychotherapy), despite significant improvement in mood, were not ob-
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 161 served to differ from untreated mothers or early remission mothers either on sensitive-insensitive or intrusive-withdrawn dimensions in face-to-face interactions with their infants (Cooper and Murray, 1997). It should be noted that these studies may have been restricted in their ability to find an impact of treatment on parenting in that the initial level of disturbance in parenting in these community samples may have been relatively minor. In a third study, Fleming, Klein, and Corter (1992) investigated a com- munity sample of women with self-reported depression who were treated with group therapy. Despite limited changes in ratings of depression, the treated mothers made more noninstrumental approaches to their infants, and the infants decreased in amounts of crying and increased in noncry vocalizations. In a recent small sample study, in contrast to these three studies of psy- chotherapy, the intervention for postpartum depression was antidepressant medication treatment (Goodman et al., 2008). Six months after beginning treatment, the postpartum depressed mothersâ scores on the Beck Depres- sion Inventory were not significantly different from the well mothers. And although the depressed mothers as a group did not show a significant improvement in parenting over time, reductions in depression, after 12 weeks of treatment, were associated with (1) improvements in the quality of their interaction with their infants and (2) improvement in the infantsâ quality of interaction, although only for their quality of play. Furthermore, improvements in mothersâ quality of interaction after 12 weeks of treatment accounted for changes in infantsâ positive affect. Others, such as Weissman et al. (2006b), have examined the effect of parentsâ treatment for depression on psychopathology in the children, but without examining potential changes in parenting as a possible mechanism. Those studies are reviewed in Chapter 7. RESEARCH GAPS Although strong evidence now supports the breadth and extent of as- sociations between depression in parents and adverse outcomes in children, there remain many unanswered questions. In particular, many questions remain regarding mediation and moderation of those associations. In terms of mediation, more studies are needed to test specific aspects of parenting and other potential mediators of associations between depression in par- ents and child functioning. In this regard, the committee noted the strong potential of studies designed to test the effectiveness of interventions aimed at reducing the level of constructs that have been found to mediate associa- tions between depression in parents and outcomes in children, for example, particular aspects of parenting. Such experimental designs can be strong tests of mediation.
162 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN In terms of moderation, more studies are needed to reveal which chil- dren of depressed parents are more or less likely to develop problems and which parents with depression are more or less likely to have problems with parenting. Moderators might include parent characteristics, including severity, duration, and impairing qualities of their depression, social context variables, and child characteristics, among others. For example, the mod- erating roles of the childâs sex and the childâs ages at times of exposure are still not well understood, with findings suggesting that boys and girls might be affected differently depending on their ages at the times of exposures. More broadly, more studies are needed to quantify percentages of children who are affected (with specific outcomes) and those who are not and what distinguishes them. The committee notes the potential knowledge to be gained by further studies that target interventions to subsets of children with greater or lesser risk (degree of presence of moderators) to determine whether interventions need to be addressed to children at all levels of risk (do they benefit equally?) or might be focused on children at greater risk. The committee also notes several gaps in the literature related to the physical health of children of depressed parents. More tracking is needed of health care utilization, missed school days, and other aspects of daily func- tioning in association with depression in parents. In particular, we conclude that more research is needed to understand the role of maternal depression in the health outcomes of children. Furthermore, both psychological and physical health outcomes need to be addressed in longitudinal studies of healthy and chronically ill children in order to know how physical health outcomes relate to psychological outcomes. Finally, tracking of avoidable and desirable health care utilization is needed to understand the impact on health services. In addition to the research gaps in terms of unanswered questions, the committee also found gaps in relation to study design. First, tests of mediation are most informative when conducted on data from longitudinal designs, with measures of depression, parenting, and child functioning at multiple time points in order to capture the pathways. A second meth- odological issue concerns the measurement of depression in parents. The committee recognizes the staffing and time constraints that often prohibit the use of diagnostic interviews yet encourages their use whenever possible. Important questions remain about differences in association with parent- ing and child outcomes when parentsâ depression meets diagnostic criteria relative to exceeding the clinical cutoff on rating scales. Among groups who exceed clinical cutoffs will be those who would also meet diagnostic criteria and those who do not, despite their high symptom levels. Differ- ences in parenting and child outcomes between those two groups need to be understood. Third, more studies from a developmental perspective are needed. Such
ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING 163 studies need not be longitudinal but require an understanding of child de- velopment in their theoretical model, hypotheses, design (especially in terms of the ages of the children studied), and the selection and psychometric properties of the measures. Fourth, the research literature would benefit from improving on the measurement of depression in population-based surveys to enhance their potential value to address these research gaps. Specifically, the committee recognizes the limitations of a single symptom rating scale score, typically reflecting the previous week or two in a parentâs life, when the hypotheses typically concern significantly longer term effects on children of exposure to depression in a parent. Fifth, more research studies are needed to test hypotheses derived from transactional models. As just one example, more studies are needed of child factors that contribute to the development or maintenance of depression in parents, for example, premature birth, chronic or acute health problems, âdifficultâ temperament, and conduct problems. Finally, as noted through- out this chapter, more studies are needed that examine the differences in parenting styles and childrenâs behavior of the full range of parents who experience depression, including cultural and ethnic groups, those from dif- fering income levels, fathers, and grandparents who are primary caregivers of their grandchildren. CONCLUSION Depression interferes with parenting. Depression in mothers of young children is significantly associated with more hostile, negative, and dis- engaged (withdrawn) parenting. Maternal depression is significantly as- sociated with less positive parenting (warmth). Parenting quality may not improve with recovery from depression. Although depression and parenting of older children are less often studied, findings are clear that depression also interferes with the qualities of parenting needed by children in middle school and in adolescence. Although less is known about parenting in depressed fathers, the accumulating evidence suggests that depression also interferes with healthy parenting in fathers. Families with one or more depressed parents often have additional factors that generally impose risk for children, such as substance use disorders, poverty, exposure to violence, minority status, cultural and linguistic isolation, and marital conflict, which interfere with good parenting qualities and healthy child rearing environ- ments. These additional risk factors are sometimes found to work indepen- dently and at other times found to be additive or interactive with the effects of depression in parents. Depression in parents is also associated with depression in their chil- dren as well as with problems in childrenâs daily functioning, physical health and well-being, some childhood chronic conditions, increased utiliza-
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